The business of healthcare is in a constant state of flux. For Medicare Advantage plans, this reality is acutely felt through the annual cycle of Star Ratings. These ratings are not just a measure of quality; they are a critical driver of financial performance, member retention, and market reputation. When ratings fall, the pressure to reverse the trend is immense.
This was the exact situation facing a Top 5 Managed Care Organization (MCO) covering more than 30 states and over 8 million members in 2023. With some of its Medicare contracts at a critical low of 2.0 Stars, the organization faced significant risks to its quality bonus payments and competitive standing.
Leadership knew that a bold turnaround was necessary. They identified medication adherence as a strategic lever for improvement—a decision that would prove pivotal. What started as a stop-the-bleeding “pilot” program quickly blossomed into a revenue unlock.
By partnering with Carenet Health, the MCO embarked on a multi-year journey to transform its Star performance. This collaboration demonstrates how targeted operational excellence in medication adherence can directly translate to improved quality measures, better member health, and substantial financial returns.
The Challenge: A Critical Moment for Quality Performance
In 2023, the MCO’s low Star Ratings were a significant business threat, potentially costing the plan billions of dollars in lost revenue. With an ambitious goal to have 60% of its members in 4-Star or higher plans, the organization needed a strategic partner that could deliver measurable improvement at scale. The complexity of medication adherence, influenced by factors from data accuracy to member behavior, required a solution that was both technologically advanced and deeply human.
The Solution: Powering Performance with Human Expertise and Advanced Technology
Carenet and the MCO launched a comprehensive medication adherence program in mid-2023. The approach was designed to be proactive and data-driven, combining:
- Proactive Member Outreach: A multichannel engagement strategy, including calls and texts, to connect with non-adherent members.
- Clinical Expertise: Personalized interventions delivered by trained Health Advisors who offered refill support, medication education, and direct transfers to pharmacists or providers.
- Data-Driven Optimization: Continuous analysis and refinement of call scripts, member authentication protocols, and targeting strategies to maximize impact.
- Scalable Infrastructure: A robust foundation of global talent and advanced technology capable of supporting hundreds of thousands of member interventions.
This partnership was built on a shared commitment to powering change—not just for the business, but for the health of its members.
Year-Over-Year: The Journey to a Star Ratings Breakthrough (Design Note: Possibly create a side-bar style timeline?)
The path to improved Star Ratings was a testament to systematic, compounding operational enhancements.
Year 1: Building the Foundation
The initial phase focused on launching the outbound medication adherence program and establishing the operational infrastructure. While initial contact rates were modest and data quality presented challenges, this period was crucial for gathering behavioral data and creating a baseline for improvement. The foundation for future success was laid through operational discipline and a commitment to shared learning.
Year 2: Scaling Amidst Headwinds
As CMS standards toughened and national Star averages declined, the partnership scaled its outreach across Medicare, Medicaid, and Marketplace plans. Carenet refined its targeting algorithms and enhanced training for Health Advisors, leading to measurable gains – in a year when many plans’ ratings saw a decline.
- $21M+ in health plan savings were documented through improved adherence and preventive care.
- Internal compliance scores rose to 80-88%, demonstrating operational rigor even as external benchmarks became more challenging.
These internal metrics were a leading indicator of the breakthrough to come, proving the resilience of the tech + human Intelligent Engagement™ model.
Year 3: Achieving a Star Ratings Breakthrough
The systematic improvements of the previous years culminated in a significant upturn in the MCO’s 2025 Star Ratings.
- 18 contracts improved, with multiple plans achieving the 4.0-Star threshold required to unlock quality bonus payments.
- Carenet handled over 348,000 adherence targets in Q1 2025 alone, achieving a 28% completion rate; a significant increase from 21% the prior year.
- Quality compliance scores reached an exceptional 97%, surpassing the 95% target.
These results were driven by key operational innovations, including enhanced call scripts that improved member engagement, the integration of multi-channel outreach, and predictive analytics for better targeting.
Year 4: Continuing the Stars Transformation
The success of this partnership illustrates a core principle: small, consistent operational actions drive major strategic results. A timely refill reminder for a single member, when multiplied across a population, becomes a powerful force for business and health outcomes.
Strategic Business Outcomes:
- Revenue Enhancement: Each half-star improvement can generate an estimated $20M+ in additional revenue. With multiple contracts improving, the aggregate financial lift far exceeded the documented savings.
- Cost Reduction: The program delivered over $21M in medical cost savings in 2024 by improving adherence and closing preventive care gaps, which helps reduce hospitalizations and ER visits.
- Enhanced Competitive Position: The MCO moved from facing financial penalties to securing quality bonuses, strengthening its position in the competitive Medicare Advantage market.
Meaningful Health Outcomes:
- Improved Member Health: Thousands of members achieved better medication compliance for chronic conditions, preventing health deterioration.
- Barrier Resolution: Health Advisors proactively identified and resolved barriers to adherence, such as affordability, transportation, and pharmacy access.
- Enhanced Member Satisfaction: The personalized, empathetic support provided by Health Advisors built trust, improved the overall member experience, and undoubtedly enhanced loyalty and lifetime value to the plan.
Looking Ahead: Sustaining the Momentum
The partnership between Carenet and the MCO continues to evolve, with a focus on harnessing advanced AI for predictive analytics, expanding clinical resources, and enhancing multi-channel engagement. Early data for 2026 suggests the improvement trajectory will continue.
This business case is a powerful example of what is possible when organizations commit to powering change. By combining leading technology, insight-led orchestration, and operational excellence, Carenet helped transform the MCO’s Star Rating performance, delivering measurable value for the business and its members.
To read more about this leading payer’s business transformation in partnership with Carenet, read the full case study here.
To learn more about how targeted operational enhancements drive Star ratings improvement and meaningful financial returns in your business, talk with an expert.
References
- Farzandipour M, et al. “The effectiveness of tele-triage during the COVID-19 pandemic: A systematic review.” J Telemed Telecare. 2023; 29(1): 3–19. PMC9892819
- Agency for Healthcare Research and Quality (AHRQ). “Costs of Treat-and-Release Emergency Department Visits in the United States, 2021.” HCUP Statistical Brief #311. September 2024. Link
- AHRQ HCUP NEDS Overview. “Nationwide Emergency Department Sample (NEDS) 2022.” Link
- S. Department of Health & Human Services. “Tele-triage.” Telehealth.gov. Last updated July 29, 2025. Link
